Airway Skills 11:
Retrograde intubation is useful for patients who are breathing and have an anatomic problem that makes orotracheal intubation impossible or dangerous. Retrograde intubation takes up to 4 minutes to accomplish, so it is not useful in a critical emergency airway situation. However, if the patient can be BVM ventilated, this technique may be performed without loss of oxygen saturation. The retrograde intubation set is made by the Cook Co.
- Prepare for awake intubation. Anesthetize the upper airway as described in Vol II—Air Skills 10 Topical Anesthesia. Anesthetize the skin over the trachea using lidocaine. Inject a small amount of lidocaine into the trachea. Apply a BVM to keep the patient well oxygenated.
- An assistant wearing sterile gloves takes the long guidewire out of its container keeping it sterile through the process.
The Cook retrograde intubation kit
- Insert the exploring needle of the retrograde intubation kit perpendicularly into the trachea just below the cricoid cartilage and aspirate for air, confirming tracheal puncture. This needle has a stylet to prevent it being plugged with cartilage. Angle the needle craniad. Inject a few mL of 2% lidocaine into the trachea to allow the patient to avoid coughing when the wire is inserted. Insert the long guidewire through the needle through the larynx while an assistant, using a laryngoscope, watches for the guidewire to appear.
- The assistant uses Magill forceps to grasp the guidewire before it goes behind the soft palate. If the wire goes behind the soft palate, it may enter the cranium through a basal skull fracture. Pull the guidewire out of the mouth until a black ring on the guidewire enters the trachea. Remove the needle and place a clamp on the wire at skin level to guard against inadvertent removal.
- Fit the long, blunt obturator over the guidewire and pass it into the trachea. When the obturator lodges against the junction of the guidewire with the trachea, you will see another black ring on the guidewire.
Release the clamp on the guidewire and pull the guidewire the remainder of the way out through the obturator, taking care not to pull out the obturator. When the wire is pulled out, the obturator is advanced further down the trachea.
- Place an ET tube over the obturator into the trachea. If the ET tube is caught at the arytenoids, pull back an inch, turn 90 degrees counterclockwise, and advance. Then remove the obturator. Test for correct placement as usual.
An advantage of using the retrograde technique is the ability to stop and ventilate the patient while conducting the technique. Retrograde intubation is most useful when the anatomy is distorted by masses or hematomas.
Sanchez TF. Retrograde intubation. Anesth Cl North Amer. 1995;13:439-476.